Cleft lip and palate: evaluation of the psychological impact using the Rosenberg self-esteem scale

GLAESER, ALESANDRA; COSTA, SADY SELAIMEN DA; COLLARES, MARCUS VINICIUS MARTINS

ABSTRACT

Introduction:

Cleft lip and palate is the most frequent malformation of the head region and affects more than 10 million people worldwide. This study aims at evaluating the selfesteem in patients with cleft lip and palate and comparing that with the self-esteem of non-affected individuals during followup at the Department of Craniomaxillofacial Plastic Surgery of the Hospital de Clínicas of Porto Alegre.

Methods:

This is a cross-sectional, contemporary study with 160 participants, comprising 80 patients with cleft lip and palate who have already undergone surgical procedures for correcting the condition and 80 non-affected students and employees of the publicschool system as a control group. We used a questionnaire to characterize the group and the Rosenberg self-esteem scale for data collection.

Results:

There was a significant difference between groups in terms of marital status, schooling, and school retention. Patients with a cleft lip and palate had lower levels of self-esteem than non-affected individuals. Among them, the individuals with bilateral clefts or complete clefts; female gender; economic strata of D/E; low level of schooling; families reconstituted during childhood; and with unsatisfactory results concerning communication, dentition, and lip scar also showed lower levels of self-esteem.

Conclusion:

There was a significant relationship between cleft lip and palate and low self-esteem.

Keywords:
Cleft lip; Mental health; Congenital abnormalities; Self-image; Nursing

RESUMO

Introdução:

A fissura labiopalatina é a malformação mais frequente da região da cabeça e afeta mais de 10 milhões de pessoas no mundo. O objetivo do estudo foi avaliar a autoestima em pacientes portadores de fissura labiopalatina em acompanhamento no Serviço de Cirurgia Plástica Craniomaxilofacial do Hospital de Clínicas de Porto Alegre, comparando-os com indivíduos não fissurados.

Métodos:

Estudo transversal contemporâneo, com 160 participantes, sendo 80 pacientes com fissura labiopalatina já submetidos a procedimentos cirúrgicos relacionados à afecção e, como grupo controle, 80 alunos e funcionários da rede pública de ensino. Um questionário para caracterizar o grupo e a escala de autoestima de Rosenberg foram utilizados para a coleta de dados.

Resultados:

Houve diferença significativa entre os grupos quanto ao estado civil, escolaridade e repetência escolar. Os pacientes com fissura labiopalatina apresentam níveis de autoestima menores em relação a indivíduos não afetados. Dentre eles, os subgrupos dos indivíduos com fissura bilateral, fissura completa, do gênero feminino, classe econômica D/E, baixa escolaridade, situação familiar reconstituída na infância e com resultados não satisfatórios em relação à comunicação, dentição e cicatriz de lábio também mostraram níveis de autoestima menores.

Conclusão:

Houve relação significativa entre fissura labiopalatina e baixa autoestima.

Descritores:
Fenda labial; Saúde mental; Anormalidades congênitas; Autoimagem; Enfermagem

INTRODUCTION

Cleft lip and palate (CLP) is a congenital anomaly that affects approximately one in every 700 live births¹1 Dixon MJ, Marazita ML, Beaty TH, Murray JC. Cleft lip and palate: understanding genetic and environmental influences. Nat Rev Genet. 2011;12(3):167-78. DOI: http://dx.doi.org/10.1038/nrg2933
http://dx.doi.org/10.1038/nrg2933... . These deformities can cause functional problems in the dental arch, chewing, breathing, and hearing²2 Tannure PN, Oliveira CA, Maia LC, Vieira AR, Granjeiro JM, Costa Mde C. Prevalence of dental anomalies in nonsyndromic individuals with cleft lip and palate: a systematic review and metaanalysis. Cleft Palate Craniofac J. 2012;49(2):194-200. DOI: http://dx.doi.org/10.1597/10-043
http://dx.doi.org/10.1597/10-043... . The difficulty in efficient communication and the compromise of the physical appearance make individuals with CLP a possible target of derogatory adjectives in social groups. These physical and functional changes may lead to other potential damages in patients’ lives: the psychosocial ones³3 Chuo CB, Searle Y, Jeremy A, Richard BM, Sharp I, Slator R. The continuing multidisciplinary needs of adult patients with cleft lip and/or palate. Cleft Palate Craniofac J. 2008;45(6):633-8. PMID: 18956932 DOI: http://dx.doi.org/10.1597/07-048.1
http://dx.doi.org/10.1597/07-048.1... .

Facial appearance has a profound influence on social environments, personality development, and educational progress. People with CLP may present unfavorable levels of anxiety, depression, social phobia, self-esteem, and quality of life⁴4 Coutinho ALF, Lima MC, Kitamura MAP, Ferreira Neto J, Pereira RM. Perfil epidemiológico dos portadores de fissura orofaciais atendidos em um Centro de Referência do Nordeste do Brasil. Rev Bras Saúde Matern Infant. 2009;9(2):149-56. DOI: http://dx.doi.org/10.1590/S1519-38292009000200004
http://dx.doi.org/10.1590/S1519-38292009... .

The measurement of self-esteem has been conducted worldwide via the Rosenberg self-esteem scale (RSES), which can classify selfesteem in adolescents, adults, and the elderly⁵5 Santos P, Maia J. Análise factorial confirmatória e validação preliminar de uma versão portuguesa da escala de auto-estima de Rosenberg. Psicol Teor Invest Prát. 2003;2:253-68..

The importance of the topic and the limited number of studies using reliable assessment tools justify our interest in this subject.

OBJECTIVE

We aim to evaluate the self-esteem of individuals with CLP compared with individuals not affected by the condition, to determine possible factors that influence the self-esteem of these patients, and to identify the most affected subgroups.

METHODS

This crosssectional, contemporary study comprised 160 individuals of both genders aged between 12 and 50 years. The study participants were equally divided into two groups. The G1 or exposed group consisted of patients with CLP, who had already undergone a surgery related to the condition, followed by craniomaxillofacial plastic surgery at the Hospital de Clínicas of Porto Alegre, RS, (HCPA). The G2 or control group consisted of individual students and employees of the public-school system in the same city without CLP.

The minimum age of individuals for inclusion in the study was determined to be 12 years to ensure ability to understand the issues of self-esteem.

The exclusion criteria for both groups were the presence of any type of central hearing syndromes or dysfunctions. The individuals or legal guardians who did not provide consent for their inclusion by signing the informed consent form (ICF) or who did not adequately fill out the questionnaire were excluded from the study.

The G1 group consisted of patients who attended the appointment at the Cleft Lip and Palate Ambulatory. Patients and/or family members were informed about the study and presented with the ICF. Subsequently, self-esteem tests using RSES and a structured questionnaire, formulated specifically for this study, were conducted. Data were also compiled from the medical records. The G2 individuals were selected from the municipality’s Education Department of a public school.

All students and school staff received sealed envelopes with the study cover letter, the structured questionnaire, and the ICF. For the inclusion of students under the age of 18 years, documentation for parents or guardians was sent. After the return of the documentation, a draw of 50 students under the age of 18 years and 30 individuals over the age of 18 years was conducted. At the school, in a reserved room, the self-esteem was tested using RSES for all included individuals.

Data collection was carried out from August to December 2012.

For data collection, a questionnaire was prepared for each research group. For the G2 group, the questionnaire included questions about personal information and questions related to schooling, school retention, economic class, and family situation. For the G1 group, in addition to the parameters mentioned above, questions related to CLP classification, surgical procedures, and healthcare institutions where they were when selected were also included.

The results were evaluated in terms of communication, dentition, functionality, and aesthetics of lips and nose with the help of an assisting team including a speech therapist, dentist, otorhinolaryngologist, and plastic surgeon, respectively. Patients were asked about their opinions on the results.

RSES used in this study is a scale developed for the evaluation of self-esteem and is used globally. RSES consists of 10 items with questions regarding the feelings of self-respect and self-acceptance. It was adapted to Portuguese with good psychometric indices. The sum of the scores for the 10 items provided the final score on the scale, which ranged from 10 to 40. The results were categorized as high, normal, and low self-esteem⁶6 Sbicigo JB, Bandeira DR, Dell’Aglio DD. Rosenberg Self-Esteem Scale (RSS): factorial validity and internal consistency. Psico- USF. 2010;15(3):395-403. DOI: http://dx.doi.org/10.1590/S1413-82712010000300012
http://dx.doi.org/10.1590/S1413-82712010... . This study and the ICF were approved by the Research and Post-Graduation Group of HCPA and its Committee of Research Ethics under protocol number 11-0021. Authorization was requested from the Education Department of Porto Alegre to conduct the research at the school. No permit was required for using RSES .

RESULTS

Initially, we characterized the sample as presented in Table 1. The sample was mostly homogeneous with unpaired groups. There was a significant difference only between groups with regard to marital status, schooling, and school repetition.

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Table 1
Characterization of the sample.

A significant association was observed between CLP and self-esteem (p = 0.046). The CLP group had a significantly higher proportion of individuals with normal and low self-esteem, as can be seen in Figure 1. In the analysis of the CLP group shown in

Figure 1
Association between self-esteem and cleft lip and palate.

Table 2, the variables that were found to be associated with low self-esteem in the CLP group were female gender, incomplete elementary education or complete elementary education, D/E strata, and reconstituted family during childhood.

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Table 2
Multinomial logistic regression analysis to assess factors independently associated with normal and low self-esteem.

Table 3 shows the group under study. With regard to the classification of the cleft, 64 (80.0%) individuals had lip and palate clefts, 56 (70.0%) had unilateral clefts, and 65 (81.2%) had complete clefts. With regard to treatment location for CLP, 47 individuals (58.8%) were operated by the plastic surgery service only at HCPA, whereas 14 (17.5%) underwent all surgeries at other institution(s) but were referred to the Cleft Lip and Palate Ambulatory for further assistance; 19 (23.8%) patients underwent surgical procedures at other institution(s) and the plastic surgery service.

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Table 3
Characterization of the CLP group.

According to the assisting team for patients with CLP, the communication skills of 31 (38.8%) patients was considered to be good, and 30 (37.5%) were assessed to have poor communication skills. With regard to dentition, 36 (45.0%) were evaluated to have good dentition, and 32 (40.0%) were found to have poor dentition. Furthermore, according to the team, the lip aesthetics of 39 (48.8%) individuals were considered to be good, whereas nose aesthetics were considered to be good in 53 (66.3%) of the affected individuals.

Of the patients with CLP, 60 (75.0%) were dissatisfied with one or more of the evaluated items, and dentition presented the highest indices for dissatisfaction, 35 individuals (43.8%), followed by lip aesthetics with 31 (38.8%) dissatisfied individuals. The number of complaints concerning communication and nose aesthetics was lower, as shown in Table 3.

Table 4 describes the association between low self-esteem and fissure classification (p = 0.026). Patients who had undergone only lip surgery (for cleft lip) were associated with higher self-esteem than others (p = 0.047). Further, an association between the quality of communication and dentition and self-esteem (p < 0.001 and p = 0.031, respectively) was also observed.

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Table 4
Association of cleft lip and palate group variables with self-esteem.

Individuals who wanted to improve communication and lip aesthetics were more likely to have a low selfesteem (p < 0.001 and p = 0.006, respectively). Finally, all those who were affected and had a low self-esteem wanted to improve their results (p < 0.001).

DISCUSSION

Patients’ perception of CLP with regard to its impact on their life is recognized as an important health indicator. There is a notable consensus in the reports from CLP patients concerning the difficulties faced by them and the set of negative emotions involved, such as anxiety, fear of social assessment, low self-esteem, unfavorable body image, and social phobia⁷7 Bastos PRHO, Gardenal M, Bogo D. The Social Adjustment of Bearers of Craniofacial Abnormalities and the Humanist Praxis. Int Arch Otorhinolaryngol. 2008;12(2):280-8.,⁸8 Noor SN, Musa S. Assessment of patients’ level of satisfaction with cleft treatment using the Cleft Evaluation Profile. Cleft Palate Craniofac J. 2007;44(3):292-303. PMID: 17477746 DOI: http://dx.doi.org/10.1597/05-151
http://dx.doi.org/10.1597/05-151... .

Self-esteem is considered an important indicator of mental health⁹9 Roberts RM, Mathias JL. Psychosocial functioning in adults with congenital craniofacial conditions. Cleft Palate Craniofac J. 2012;49(3):276-85. DOI: http://dx.doi.org/10.1597/10-143
http://dx.doi.org/10.1597/10-143... and one of the factors that interferes the most with human relations, educational progress, and psychosocial development. RSES is currently the most widely used instrument for the evaluation of self-esteem worldwide⁶6 Sbicigo JB, Bandeira DR, Dell’Aglio DD. Rosenberg Self-Esteem Scale (RSS): factorial validity and internal consistency. Psico- USF. 2010;15(3):395-403. DOI: http://dx.doi.org/10.1590/S1413-82712010000300012
http://dx.doi.org/10.1590/S1413-82712010... and is widely accepted in the scientific community.

The results of this study indicate that single status, low educational level, and school repetition are seen in a higher proportion in patients with CLP than in nonaffected individuals.

Some studies¹⁰10 Broder HL, Richman LC, Matheson PB. Learning disability, school achievement, and grade retention among children with cleft: a two-center study. Cleft Palate Craniofac J. 1998;35(2):127-31. PMID: 9527309 DOI: http://dx.doi.org/10.1597/1545-1569(1998)035<0127:LDSAAG>2.3.CO;2
http://dx.doi.org/10.1597/1545-1569(1998... ,¹¹11 Domingues ABC, Picolini MM, Lauris JRP, Maximino LP. Desempenho escolar de alunos com fissura labiopalatina no julgamento de seus professores. Rev Soc Bras Fonoaudiol. 2011;16(3):310-6. DOI: http://dx.doi.org/10.1590/S1516-80342011000300012
http://dx.doi.org/10.1590/S1516-80342011... have indicated on the association of CLP with school performance of affected individuals. Consequently, these individuals also present higher rates of school retention. The emotional aspects of children with CLP interfere with their learning ability in early school years. There is no report associating facial deformity with intellectual deficit; on the contrary, children with CLP have intellectual conditions similar to those of children considered normal for good school performance.

A school is a child’s first non-family contact with the society, and facial aesthetics form the first impression one makes of an individual. Children with CLP are not spared criticism by their peers, which in turn negatively affects their academic, social, and emotional lives. School failure may also be related to changes in auditory function and/or communication, which are essential for the learning process.

We observed that young adults with CLP feel greater difficulty in an interpersonal and affective relationship, in accordance with previous results¹²12 Ribeiro EM, Moreira ASCG. Atualização sobre o tratamento multidisciplinar das fissuras labiais e palatinas. Rev Bras Promoç Saúde. 2005;18(1):31-40.. This fact is evident in adolescence, as it is during this phase that a greater concern with physical appearance arises. If individuals do not feel satisfied with their appearance, they develop a feeling of inferiority and become insecure.

In the self-esteem analysis in this study, significant indices of low self-esteem were observed in women. Studies indicate that women express a greater dissatisfaction level with their appearance; this feeling is justified given the society pressure on women to have an attractive appearance¹³13 Andrade D, Angerami ELS. A auto-estima em adolescentes com e sem fissuras de lábio e/ou de palato. Rev Latinoam Enferm. 2001;9(6):37-41. DOI: http://dx.doi.org/10.1590/S0104-11692001000600007
http://dx.doi.org/10.1590/S0104-11692001... ,¹⁴14 Singh VP, Moss TP. Psychological impact of visible differences in patients with congenital craniofacial anomalies. Prog Orthod. 2015;16:5. DOI: http://dx.doi.org/10.1186/s40510-015-0078-9
http://dx.doi.org/10.1186/s40510-015-007... . Thus, women with CLP feel inferior, making it difficult for them to have social and affective interactions.

In the analysis concerning family structure, we observed low self-esteem in patients with CLP whose families during childhood did not include a father and a mother. The experience of parental separation or non-cohabitation of one of the parents causes psychoemotional damage with varying degrees of intensity in all children.

Experiencing parental separation may have a more negative repercussion in individuals with CLP because in addition to living with the difficulties related to the condition, the lack of a family structure causes the feelings of insecurity. A family structure during childhood represents a significant maker for the affected patients as parents play an important role in the treatment.

CLP is also associated with the socioeconomic status of the individuals affected in the adult phase¹⁵15 Chan RK, McPherson B, Whitehill TL. Chinese attitudes toward cleft lip and palate: effects of personal contact. Cleft Palate Craniofac J. 2006;43(6):731-9. PMID: 17105325 DOI: http://dx.doi.org/10.1597/05-111
http://dx.doi.org/10.1597/05-111... . The results of this study show that the most disadvantaged economic classes (strata D/E) have a higher index of low self-esteem.

Individuals with CLP who experience social exclusion, along with the abovementioned problems, have difficulties with professional success because besides requiring technical and emotional competence, the professional industry seeks people with leadership and good communication skills.

An association between bilateral clefts of the lip and/or palate and low self-esteem was observed while evaluating factors related to affection. Bilateral clefts cause greater aesthetic damage, and it is more difficult to achieve satisfactory results in these patients. Concerning the classification of clefts, most individuals who underwent lip surgery without compromising the palate had a high self-esteem.

Patients who expressed dissatisfaction with lip aesthetics and phonation were more likely to have low self-esteem. All patients with low self-esteem wanted to improve their results with regard to aesthetics, lip, nose, or dentition, or functional aspects of communication.

These results agree with the results of other studies on this topic as all issues faced by the patients with CLP with regard to communication, scar of the lip, and dentition are shown to be directly related to their self-esteem.

CONCLUSION

Individuals with CLP have low levels of selfesteem compared with non-affected individuals.

Among patients with CLP, the subgroup of individuals with bilateral clefts, complete clefts, female gender, economic strata D/E, low educational level, families reconstituted during childhood, and with dissatisfaction with treatment results concerning communication, dentition, and scar further have lower rates of self-esteem.

Individuals with CLP have significant psychoemotional fragility that should be considered during their treatment. In addition to medical, speech, and dental care, nurses, and geneticists, they need psychological support throughout their growth, development, and rehabilitation periods for the condition.

COLLABORATIONS

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AG Analysis and/or interpretation of data; statistical analyses; conception and design of the study; writing the manuscript or critical review of its contents. SSC Analysis and/or interpretation of data; conception and design of the study; writing the manuscript or critical review of its contents. MVMC Analysis and/or interpretation of data; statistical analyses; conception and design of the study; writing the manuscript or critical review of its contents.

REFERÊNCIAS

¹
Dixon MJ, Marazita ML, Beaty TH, Murray JC. Cleft lip and palate: understanding genetic and environmental influences. Nat Rev Genet. 2011;12(3):167-78. DOI: http://dx.doi.org/10.1038/nrg2933
» http://dx.doi.org/10.1038/nrg2933
²
Tannure PN, Oliveira CA, Maia LC, Vieira AR, Granjeiro JM, Costa Mde C. Prevalence of dental anomalies in nonsyndromic individuals with cleft lip and palate: a systematic review and metaanalysis. Cleft Palate Craniofac J. 2012;49(2):194-200. DOI: http://dx.doi.org/10.1597/10-043
» http://dx.doi.org/10.1597/10-043
³
Chuo CB, Searle Y, Jeremy A, Richard BM, Sharp I, Slator R. The continuing multidisciplinary needs of adult patients with cleft lip and/or palate. Cleft Palate Craniofac J. 2008;45(6):633-8. PMID: 18956932 DOI: http://dx.doi.org/10.1597/07-048.1
» http://dx.doi.org/10.1597/07-048.1
⁴
Coutinho ALF, Lima MC, Kitamura MAP, Ferreira Neto J, Pereira RM. Perfil epidemiológico dos portadores de fissura orofaciais atendidos em um Centro de Referência do Nordeste do Brasil. Rev Bras Saúde Matern Infant. 2009;9(2):149-56. DOI: http://dx.doi.org/10.1590/S1519-38292009000200004
» http://dx.doi.org/10.1590/S1519-38292009000200004
⁵
Santos P, Maia J. Análise factorial confirmatória e validação preliminar de uma versão portuguesa da escala de auto-estima de Rosenberg. Psicol Teor Invest Prát. 2003;2:253-68.
⁶
Sbicigo JB, Bandeira DR, Dell’Aglio DD. Rosenberg Self-Esteem Scale (RSS): factorial validity and internal consistency. Psico- USF. 2010;15(3):395-403. DOI: http://dx.doi.org/10.1590/S1413-82712010000300012
» http://dx.doi.org/10.1590/S1413-82712010000300012
⁷
Bastos PRHO, Gardenal M, Bogo D. The Social Adjustment of Bearers of Craniofacial Abnormalities and the Humanist Praxis. Int Arch Otorhinolaryngol. 2008;12(2):280-8.
⁸
Noor SN, Musa S. Assessment of patients’ level of satisfaction with cleft treatment using the Cleft Evaluation Profile. Cleft Palate Craniofac J. 2007;44(3):292-303. PMID: 17477746 DOI: http://dx.doi.org/10.1597/05-151
» http://dx.doi.org/10.1597/05-151
⁹
Roberts RM, Mathias JL. Psychosocial functioning in adults with congenital craniofacial conditions. Cleft Palate Craniofac J. 2012;49(3):276-85. DOI: http://dx.doi.org/10.1597/10-143
» http://dx.doi.org/10.1597/10-143
¹⁰
Broder HL, Richman LC, Matheson PB. Learning disability, school achievement, and grade retention among children with cleft: a two-center study. Cleft Palate Craniofac J. 1998;35(2):127-31. PMID: 9527309 DOI: http://dx.doi.org/10.1597/1545-1569(1998)035<0127:LDSAAG>2.3.CO;2
» http://dx.doi.org/10.1597/1545-1569(1998)035<0127:LDSAAG>2.3.CO;2
¹¹
Domingues ABC, Picolini MM, Lauris JRP, Maximino LP. Desempenho escolar de alunos com fissura labiopalatina no julgamento de seus professores. Rev Soc Bras Fonoaudiol. 2011;16(3):310-6. DOI: http://dx.doi.org/10.1590/S1516-80342011000300012
» http://dx.doi.org/10.1590/S1516-80342011000300012
¹²
Ribeiro EM, Moreira ASCG. Atualização sobre o tratamento multidisciplinar das fissuras labiais e palatinas. Rev Bras Promoç Saúde. 2005;18(1):31-40.
¹³
Andrade D, Angerami ELS. A auto-estima em adolescentes com e sem fissuras de lábio e/ou de palato. Rev Latinoam Enferm. 2001;9(6):37-41. DOI: http://dx.doi.org/10.1590/S0104-11692001000600007
» http://dx.doi.org/10.1590/S0104-11692001000600007
¹⁴
Singh VP, Moss TP. Psychological impact of visible differences in patients with congenital craniofacial anomalies. Prog Orthod. 2015;16:5. DOI: http://dx.doi.org/10.1186/s40510-015-0078-9
» http://dx.doi.org/10.1186/s40510-015-0078-9
¹⁵
Chan RK, McPherson B, Whitehill TL. Chinese attitudes toward cleft lip and palate: effects of personal contact. Cleft Palate Craniofac J. 2006;43(6):731-9. PMID: 17105325 DOI: http://dx.doi.org/10.1597/05-111
» http://dx.doi.org/10.1597/05-111

Publication Dates

Publication in this collection
16 June 2023
Date of issue
Apr-Jun 2018

History

Received
10 Nov 2017
Accepted
17 May 2018

Este é um artigo publicado em acesso aberto (Open Access) sob a licença Creative Commons Attribution, que permite uso, distribuição e reprodução em qualquer meio, sem restrições desde que o trabalho original seja corretamente citado.

[1] COLLABORATIONS

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AG Analysis and/or interpretation of data; statistical analyses; conception and design of the study; writing the manuscript or critical review of its contents. SSC Analysis and/or interpretation of data; conception and design of the study; writing the manuscript or critical review of its contents. MVMC Analysis and/or interpretation of data; statistical analyses; conception and design of the study; writing the manuscript or critical review of its contents.

Variables	Total sample (n = 160)	Cleft Lip and Palate Group (n = 80)	Control Group (n = 80)	p value^* * Pearson’s Chi-square test.
Age group (years)
12-18	103 (64.4)	53 (66.3)	50 (62.5)
≥ 19	57 (35.6)	27 (33.8)	30 (37.5)	0.741
Gender
Male	75 (46.9)	42 (52.5)	33 (41.3)	0.205
Female	85 (53.1)	38 (47.5)	47 (58.8)
Marital status
Not married	128 (80.0)	71 (88.8) ^† † Statistically significant association by the test of adjusted residuals at 5% significance.	57 (71.3)
Married	25 (15.6)	8 (10.0)	17 (21.3) ^† † Statistically significant association by the test of adjusted residuals at 5% significance.	0.015
Divorced/Widowed	7 (4.4)	1 (1.3)	6 (7.5)
Education
Incomplete elementary	71 (44.4)	50 (62.5) ^† † Statistically significant association by the test of adjusted residuals at 5% significance.	21 (26.3)
Complete elementary	32 (20.0)	10 (12.5)	22 (27.5) ^† † Statistically significant association by the test of adjusted residuals at 5% significance.	<0.001
High school/College	57 (35.6)	20 (25.0)	37 (46.3) ^† † Statistically significant association by the test of adjusted residuals at 5% significance.
School retention
Yes	59 (36.9)	41 (51.3)	18 (22.5)	<0.001
No	101 (63.1)	39 (48.8)	62 (77.5)
Economic strata
E	36 (22.5)	17 (21.3)	19 (23.8)
D	48 (30.0)	22 (27.5)	26 (32.5)	0.730
C	69 (43.1)	38 (47.5)	31 (38.8)
B	7 (4.4)	3 (3.8)	4 (5.0)
Family situation in childhood
Nuclear	106 (66.3)	59 (73.8)	47 (58.8)
Reconstituted	44 (27.5)	17 (21.3)	27 (33.8)	0.133
Others	10 (6.3)	4 (5.0)	6 (7.5)
Current family situation
Nuclear	88 (55.0)	48 (60.0)	40 (50.0)
Reconstituted	53 (33.1)	25 (31.3)	28 (35.0)	0.203
Others	10 (6.3)	2 (2.5)	8 (10.0)
Living alone	9 (5.6)	5 (6.3)	4 (5.0)

Variables	Normal self-esteem
Variables	Adjusted OR (95% CI)	p value	Adjusted OR (95% CI)	p value
CLP group	2.20 (0.90-5.40)	0.085	3.86 (1.15-12.9)	0.028
Women	1.82 (0.80-4.13)	0.153	3.18 (1.07-9.50)	0.038
Level of schooling
Incomplete elementary	1.70 (0.63-4.55)	0.293	4.74 (1.11-20.2)	0.035
Complete elementary	1.01 (0.33-3.13)	0.989	5.29 (1.16-24.1)	0.032
With school retention	1.53 (0.56-4.16)	0.405	0.64 (0.18-2.27)	0.491
Class of D/E	1.35 (0.59-3.08)	0.483	4.44 (1.40-14.1)	0.012
Childhood family situation
Nuclear	1.0		1.0
Reconstituted	1.63 (0.58-4.56)	0.353	4.19 (1.16-15.1)	0.029
Other	0.38 (0.07-1.97)	0.250	1.08 (0.18-6.63)	0.934

Variables	Total sample (n = 80)
Classification of the cleft
Lip and palate	64 (80.0)
Lip	12 (15.0)
Palate	4 (5.0)
Unilateral	56 (70.0)
Bilateral	24 (30.0)
Complete	65 (81.2)
Incomplete	15 (18.8)
Repair surgery
Lip surgery only	12 (15.0)
Palatal surgery only	4 (5.0)
Lip + palatal surgery	64 (80.0)
Treatment
Only at HCPA	47 (58.8)
Other institution(s) and HCPA	33 (41.2)
Evaluation of the results by the assisting team regarding the following:
Communication
Good	31 (38.8)
Fair	19 (23.8)
Bad	30 (37.5)
Dentition
Good	36 (45.0)
Fair	12 (15.0)
Bad	32 (40.0)
Lip
Good	39 (48.8)
Fair	21 (26.3)
Bad	20 (25.0)
Nose
Good	53 (66.3)
Fair	13 (16.3)
Bad	14 (17.5)
Patient outcome
Pleased	20 (25.0)
Dissatisfied	60 (75.0)
What do they want to change?
Communication	21 (26.3)
Teeth	35 (43.8)
Lip	31 (38.8)
Nose	17 (21.3)

Variables	High self-esteem (n = 15)		Normal self-esteem (n = 47)	Low self-esteem (n = 18)	p value
Classification of the cleft
Lip and palate	10 (66.7)		39(83.0)	15 (83.3)
Lip	5 (33.3)		5 (10.6)	2 (11.1)	0.241
Palate	0 (0.0)		3 (6.4)	1 (5.6)
Unilateral	12 (80.0)		36 (76.6)	8 (44.4)	0.026
Bilateral	3 (20.0)		11 (23.4)	10 (55.6)
Complete	11 (73.3)		38 (80.9)	16 (88.9)	0.519
Incomplete	4 (26.7)		9 (19.1)	2 (11.1)
Repair surgery
Lip	6 (40.0)		4 (8.5)	2 (11.1)
Palate	0 (0.0)		3 (6.4)	1 (5.6)	0.047
Lip + Palate	9 (60.0)		40 (85.1)	15 (83.3)
Evaluation of the results by the supporting team regarding:
Communication
Good		11 (73.3)	18 (38.3)	2 (11.1)
Fair		3 (20.0)	14 (29.8)	2 (11.1)	< 0.001
Bad		1 (6.7)	15 (31.9)	14 (77.8)
Dentition
Good		11 (73.3)	18 (38.3)	7 (38.9)
Fair		0 (0.0)	11 (23.4)	1 (5.6)	0.031
Bad		4 (26.7)	18 (38.3)	10 (55.6)
Lip
Good		12 (80.0)	22 (46.8)	5 (27.8)
Fair		2 (13.3)	12 (25.5)	7 (38.9)	0.052
Bad		1 (6.7)	13 (27.7)	6 (33.3)
Nose
Good		13 (86.7)	31 (66.0)	9 (50.0)
Fair		1 (6.7)	6 (12.8)	6 (33.3)	0.112
Bad		1 (6.7)	10 (21.3)	3 (16.7)
Patient Outcome
Pleased		10 (66.7)	10 (21.3)	0 (0.0)	< 0.001
Dissatisfied		5 (33.3)	37 (78.7)	18 (100)
What do they want to change
Communication		0 (0.0)	9 (19.1)	12 (66.7)	< 0.001
Teeth		3 (20.0)	21 (44.7)	11 (61.1)	0.059
Lip		1 (6.7)	19 (40.4)	11 (61.1)	0.006
Nose		2 (13.3)	10 (21.3)	5 (27.8)	0.600

AG	Análise e/ou interpretação dos dados; análise estatística; concepção e desenho do estudo; redação do manuscrito ou revisão crítica de seu conteúdo.
SSC	Análise e/ou interpretação dos dados; concepção e desenho do estudo; redação do manuscrito ou revisão crítica de seu conteúdo.
MVMC	Análise e/ou interpretação dos dados; análise estatística; concepção e desenho do estudo; redação do manuscrito ou revisão crítica de seu conteúdo.

AG	Analysis and/or interpretation of data; statistical analyses; conception and design of the study; writing the manuscript or critical review of its contents.
SSC	Analysis and/or interpretation of data; conception and design of the study; writing the manuscript or critical review of its contents.
MVMC	Analysis and/or interpretation of data; statistical analyses; conception and design of the study; writing the manuscript or critical review of its contents.